Focus: Communication is Key!

In countries with a high level of connectedness of the population, a central issue in vertical communication will be the control of the information accessible to populations. Dr KUO’s presentation, which focused on the relationship of the government with the mass media, is revealing in this regard. Policy makers and communicators in highly connected environments must make do with the instant availability of parallel communication channels and contradictory information which threaten to blur the government’s message, and impede behavioural change. Dr KUO showed a video taken from a Taiwanese show, featuring a young girl whose left arm and leg had – allegedly – been paralysed following vaccination. Such a video could potentially harm the government’s vaccination strategy, and the CDC, the agency in charge of the management of health outbreaks in Taiwan, was quick to prove the hypothesis wrong and issue a denial in the media. In order to prevent and absorb such competing claims, Dr KUO insisted on the need for policymakers to be proactive, and issue information as much as possible before the media, to be reactive, and most importantly to build trust amongst its population through early announcement, but also transparency and an ability to listen to the population.

As clearly illustrated by his finishing quote: “to declare war on the media, though tempting, is a game you will never win.”

Dr KUO’s presentation focused, quite significantly, on the importance of communication between decision makers and the media. The media is indeed one of the most institutionalised channels through which the information produced by decision makers will be passed on to the public. It is also the vector through which the state of mind of a given audience will be made visible, either indirectly, through reports and articles, or directly, through op-eds and tribunes.

A certain degree of management of the media space is therefore necessary if decision makers want to control the messages that they give out. Dr KUO advocated gaining a certain degree of control over the information produced, but also of controlling, as in “taking the temperature of”, the state of mind of the population. Thus a good timing, and transparency in the communication strategy were put forward as ways of dealing with the conflicting information that can emerge in the media – such as the story of the paralysed young girl that we mentioned earlier: produce information before the media does, be honest in communicating the amount of information that you know and that you don’t know. The perception of transparency will strengthen trust, thus making populations less vulnerable to competing claims. Dr KUO also insisted on the need for decision makers to demonstrate care. In his words, “people don’t care how much you know, they just want to know how much you care.” The projection of care is an important component of an effective communication strategy, to which we will come back to as we reflect on the final part of this session.

Dr KUO also put forward the importance of knowing how an audience reacts. It is not enough to determine “the right message and the right vector for the right audience”; one must also establish whether such a message has been heard, in the first place, and whether it is being well understood in the second. This endeavour links back to the issue of the “behavioural gap”, which we mentioned earlier on. For this purpose, interesting tools were put in place as part of Taiwan’s communication strategy, to “take the temperature” of the population during the Pandemic A/H1N1 outbreak. Reports on the pandemic in the major media channels were thus closely monitored as a way of evaluating the degree of concern within the population. A toll-free hotline was also set up, which served the dual objective of handing out information to the public and informing decision makers on the state of mind of the population: number of calls indicating the level of concern, type of questions posed indicating possible gaps in the communication campaign, etc. By closely following the “mood” of the population, decision makers can palliate the emergence of conflicting information by answering concerns and tailoring messages before the media does, and reframing an unclear message before it is contradicted, thus avoiding credibility loss and strengthening confidence.

Singapore’s communication strategy on the Pandemic A/H1N1 has been quite country and culture-specific. Singapore’s response system, the DORSCON (Disease Outbreak Response System), evaluated pandemic severity using a classification distinct from that of the WHO, integrating the parameters of transmissibility and virulence of a disease.

Singapore’s communication strategy was also remarkable for its directive style. In the words of Dr MENON, “soft warnings and reassurances do not work”, whilst “fear can be a constructive emotion.” Thus rather directive measures, in place of incentive ones, were communicated to the public – Home Quarantine Orders for travellers returning from Mexico and voluntary quarantine for those returning from other affected areas, travel restrictions through “strong” advise to postpone or avoid non-essential travel – travellers which had stayed at the Metropark Hotel Wanchai, in Honk-Kong, were requested to call the hotline of the Ministry of Health, deployment of thermal scanning in air, sea and land checkpoints.

Such measures, which were well accepted by the Singaporean population, could have been difficult to implement in a number of other countries. The position of the Singaporean government, which is endorsed by its population, is that “it is better to err on the side of over-reaction that under-reaction.”

Dr MENON’s presentation also illustrated the difficulties that may arise from the articulation of local and global governance levels. For instance, it would seem that Singapore, despite its independent system for evaluating the severity of the pandemic, dovetailed the progressive step-up of WHO phases, only to reverse this progression and retrograde shortly after, when it appeared that the disease was less serious than expected. This “evident confusion in the responses of Government Ministries and organisations having to amend processes mid-stream” was caused by the perceived “loophole in WHO’s pandemic alert system”, or more generally by the friction that can arise between global (WHO) and local standards.

The importance of local/national specificities in elaborating an adequate communication strategy does not preclude however the existence of a global framework actively shaping it. Dr MENON underlined that the specific content of Singapore’s management of the Pandemic A/H1N1 outbreak took place under the umbrella of the WHO. Information between both levels circulated, and was either adapted at the local/national level from the global one, or compatible with it. Specific communication styles did not send contradictory signals.

A summary of proceedings after the colloquium which was held on November 28, 2009 in Taipei

After the SRAS and the H5N1 avian influenza, the outbreak of the new influenza A/H1N1 highlighted the importance of communication in pandemic preparedness and response. The uncertainties regarding the emerging disease and the difficulty in predicting its evolution made decision-making delicate. The fear of creating panic, on the one hand, and the desire to promote the necessary behavioural changes from the public, on the other, was a balance that proved at times difficult to keep. Some national authorities were accused of fear-mongering, or on the contrary of downplaying real existing risks in order to reduce anxieties. The eagerness to demonstrate political action resulted at times in unnecessary if not problematic measures being taken, on the grounds that populations needed to be reassured (closing of borders, culling of pigs). The experience of past crises also proved to be a double-edge sword: lists and routines of actions and communications existed and were ready to be used, but they simultaneously had to be adapted and changed, and such changes in turn had to be explained. A need thus emerged for “flexible, flipside communication”, or in other words a communication strategy based on the idea that “today the recommendations are such, but tomorrow they could and will certainly sound different. So keep listening”.

On the positive side, the crisis demonstrated achievements, such as a high level of transparency and efficient communication strategies by the WHO, the (US) CDC, and other actors. If a close and thorough study of the experience of the new influenza remains to be written, the A/H1N1 outbreak has raised issues and lessons that are common to any global public health crisis communication strategy.

The first lesson, which now seems to have been widely acknowledged but may not yet be fully implemented, is that communication not only matters, but is key to the successful management of any crisis.

This being acknowledged, the second lesson is that communication should be first and foremost about “horizontal communication”, i.e. about the getting together of decision-makers from different sectors and organisations to exchange information and analyses through transparent processes and to coordinate their responses to maximise impact. Within one given country, how do different ministries and agencies coordinate to respond to a public health crisis? At the global level, how does the WHO play its coordinating, and information-pooling role, how does it rationalise the global response? What options exist to improve such communication processes?

The third lesson underlines the importance of “vertical communication”, between decision-makers and the public, and “transversal communication”, amongst members of the public. Often, fear of panic and the desire to “reassure” dominate the strategies to manage public health crises. This can lead to discourses fostering anxiety or on the contrary disinterest, rather than the development of a social space nurturing behavioural change and preparation. What options can we think of to circumvent such a paradox? Could and should public health communicators rely more on bottom-up strategies (empowerment of the public) or “transversal communication”?

Finally, the rise of new media (one needs only to think of twitter) has already revolutionised public health communication. What are the innovative trends and options currently being developed to improve global public health communication? What can we learn from such experiences?

The speaker talked about the challenges of facing the H1N1 in the Taipei region and how drawing upon previous pandemic experiences helped ensure a successful outcome.

The SARS epidemic of 2003 highlighted the communication difficulties between local government and central government. The command structure was changed in the aftermath of SARS. Under the revised system, the central government operated the command center and local governments executed these commands. This ensured that messages delivered during H1N1 were more consistent.

The government had two phases of dealing with H1N1:1.Stage of containment – June 2009. Many foreign tourists so hotels used as checkpoints; and2.Stage of mitigation – September 2009. Coincided with the Deaf Olympics in Taipei. This was at the height of the pandemic. Letters sent to guests.

The 2009 H1N1 campaign was successful because it was simplicity (message was easy to understand), credibility and delivered in a unified voice.

From the Global response to Avian Influenza through Pandemic A/H1N1, towards "One Health"

How much information should governments communicate to the public? How transparent should they be? Should they communicate all the information that they have, or rather leave aside information that could run the risk of being misinterpreted? And should honesty be preferred to transparency?

This question, which characterises all policy-making, is made even more complex here by the existence of what Dr. VANDERSMISSEN called the “scientific dilemma”. Science on the emergence, development and evolution of a pandemic is not fixed – this was clearly exemplified by the emergence of a pandemic of porcine origin in the South American continent, when a pandemic of avian origin was expected to develop in the Southeast Asian region. The pandemic A/H1N1 also turned out to be, until now, far less lethal than originally predicted.

As summarised by Dr VANDERSMISSEN, we have entered an era of “infectious uncertainty”. How much of this uncertainty should be communicated to the public? Would trust/serenity/obedience of an audience, depending on the primary objective of the communication strategy, be best established by a self-confident government who might need to change its message following the evolutions of science? Or by an executive acknowledging the gaps in its information and advising to “keep listening” to possible evolutions in its recommendations?

[inset side="left" title="Alain Vandersmissen"] has been the Coordinator of the External Response of the European Commission to the Avian Influenza Crisis since January 2006. In this capacity, he has strongly contributed to the orientations and achievements of the global AI response. He is one of the promoters of the evolution of the AI response towards a “One Health” approach addressing all major risks at the interface between animals, humans and ecosystems. [/inset]

Lessons for the Global Management of Health and Environmental Risks and Crises

The term “Avian Influenza” (AI) refers both to: 1/ the existing and related avian influenza epizooty and epidemic, and 2/ the possibility of an influenza pandemic, that would result from a mutation of the H5N1 virus.

The issue of AI therefore implies two necessities: 1/ the need to control the existing avian influenza virus and 2/ the need to prepare for the next pandemic.

The reaction to the AI issue has thus articulated itself, over the years, in two movements: 1/ a strong solidarity drive, from the better prepared, to the less prepared and 2/ a “national preparedness drive”, as the majority of countries strove to strengthen their own capacity to respond to an AI outbreak/pandemic. The tension between those two dimensions of the management of AI contributed to the build-up of a strong mobilisation, from very different communities (animal health, human health, environmental health, security, media, private sector, etc.). This process of mobilisation resulted in the emergence of what appears to be, with the benefit of hindsight, a real “global fight against avian influenza”, which reaps significant results, as this report highlights. Such a dynamic may not last forever, however, as a lurking fatigue with the issue seems to be spreading amongst actors, and threatening past and current efforts. The new “One World One Health” agenda could, in this regard, prove to be a necessary option to remobilise actors, and consolidate the outcomes of the fight against AI.

Before highlighting some key lessons from the fight against AI, one should draw some key features of the architecture of the global governance of avian influenza.

Which Global Governance of AI?- Governing AI at the global level has been a fluid process, as it took some time to structure the large range of actors that had mobilised. Today still, as the agenda One World One Health is gains momentum, the exact role played by the different institutions involved in this processmight start to shift again.- States are the key actors, as they raise political momentum at the global level, and as no possible response/control/preparedness is possible without them.- Intergovernmental Organisations are very important supporting actors in the fight against AI; it is important in this regard to understand their role and limits. If IOs are faced with some problemsi.e. bureaucratic problems, traditional aid issues), they also proved to be extremely innovative.- The regional level can have a facilitating effect on the global fight against AI. However, strong discrepancies exist between the regional organisations.- A strong mobilisation was possible thanks to yearly conferences at the high political level; high political support from the national level: continuity of leadership; simulations; a cautious use of the “security” agenda.- Coordination, which is always a problem at the global level, appeared to be less of a problem her thanks to global, regional, national and institutional coordinators, who had both a high visibility and sufficient time, and used frequent meetings of all stakeholders to insure coordination worked. UNSIC was useful but not very present on the ground; the question of its persistence in 2009 is still open.- The Global Governance of AI confirms that strengthening existing organisations and coordination mechanisms can prove more efficient than creating new institutions.

LESSONS from a Global Fight:- One needs a blend of horizontal and vertical approaches to global health issues to ensure that both animal and human health systems and the specific realities of a given diseases are taken cared of.- Communication is a key factor.- Surveillance systems are now better, but they can still be improved, and this needs to be done.- A rapid emergency response requires long term investment. Even fire brigades have structural costs.- Decision-making in grey environments implying investing time and money in research, but one should accept the fact that there will never be enough knowledge, and that grey decisions will thus have to be taken.- Global norms are essentials, but they need to be adapted to local settings. Furthermore, a robust system to check on implementation of global norms needs to be established.- Controlling epizootic will always imply a risk for livelihoods and an increase in poverty levels. Sustainable financial solutions have to be found. Eradication will always be extremely difficult with complex ecologies and should therefore take place as soon as possible, before the virus spreads.- The best options to respond to human cases is to strengthen [one] health systems. This implies an increase in the surveillance and response capacity, the distribution of pharmaceutical options, and the surge capacities. Non pharmaceutical options are important, but they cannot replace the medical response.- Pandemic preparedness is a complex and constant effort. It requires both: 1/specific health efforts and multisectoral efforts to detect and solve gaps and vulnerabilities (importance of simulations); 2/ the recognition that there is no “zero risk”. Indeed, the real issue may be the resilience of the system and its capacity to survive to such a traumatic experience.- Global Health and the virus-sharing issue would strongly benefit from a reformed WHO sharing system, and more widely a solution has to be found to improve access (included delivery) to drugs and vaccines against emerging diseases of global impact.

The future of AIPrevention and preparedness efforts are difficult to evaluate. However in terms of surveillance and control, the effects of the fight are positive, and the world seem better prepared now than five yearsago to face an AI pandemic. Will this situation last? AI will remain a problem for some countries where the virus has become endemic and where, as soon as efforts diminish or falter, AI will re-emerge. People are still dying from H5N1. The pandemic risk will last. The fight is not over.

In July 2008, several persons interviewed in Washington D. C. were positive that if Senator Obama were to be elected, more funding would be dedicated for the management of global health issues and health systems. However, the advent of the financial crisis may make health issues appear like less of a priority for many decision-makers.

Drawing on his clinical experience, Professor Soebandrio demonstrated how communicating risk is similar to preparing medicine:

Must find an indicator – just as a patient demonstrates symptoms, so does a community. Considering the symptoms, the doctor decides on further action and in the same way a government will consider the need to communicate.

Ingredient – patients can have differing reactions to medicine and communities demonstrate the same variability to public health messages. The content of the message might need to vary from country to country.

Dose – how much information should we give? If too much medicine is administered the patient will not heal, if the public is bombarded with public health messages people will stop listening.

Method and route of administration – just as medicines and medical technology have evolved, so to have communication methods. This does not necessarily mean that traditional methods should be ignored at the expense of modern methods.

Duration – when to start and stop, when to follow up. The duration of a course of treatment is integral to a patient’s well being; too short a treatment and the illness will linger, too long a treatment and the effectiveness may be comprised. Medicine is administered to improve one’s condition, not to provide a new burden. This logic is transferable to risk communication.

Ms Leboeuf wove previous speakers themes together to sharply illustrate two recent examples in France during the H1N1 outbreak.

An apparently arbitrary decision to not close infants’ schools even if cases of H1N1 were reported, reversing a previous decree that schools must be closed if three cases are detected, indicated the importance of ensuring that relevant information is communicated and that bureaucracies must be flexible enough to deal with new crises rather than rely on previous models of action.

Her second example described a situation whereby H1N1 vaccines were initially available to strictly defined groups and then later to broader groups. While this change in process was not official, people seeking vaccination still had to present a case as to why they should be vaccinated. This meant the boundary was no longer strictly medical and bureaucratic, but had expanded to be negotiable, thereby introducing additional layers of complexity and power.

Ms Leboeuf noted that medical professionals now must remind patients that although what they have been advised is true for today, it might not be true for tomorrow. This is a departure from established patterns of medical advice.

Distributing contraception to Pakistan’s large rural population has been a challenge for Glaxo Smith Kline. Rather than utilise the increasingly popular social networking sites and other digital media, the company has successfully resorted to less technologically sophisticated methods. Glaxo Smith Kline has utilised radio advertising to reach and mobilise the rural sector. Radio is part of an integrated communication model that also includes interpersonal and community mobilization through activities such as marketplace interviews and roadshows.

Glaxo Smith Kline was particularly successful in distributing and encouraging use of contraception. Realising that the information provided with contraception medication was in small print and hard to read, serving no purpose other than “basically to frighten the consumer”, the company began circulating cassettes, recorded in local dialects, that answered frequently asked questions about the medication.

Communication is part of the process of the revelation of truths. A truth is not a given fact as the reaction of the public influences what the truth is. This is the relationship between observed and the observation. The nature of a truth to be communicated can be changed. It is a systemic (that is, linguistic and symbolic) exchange in which dimensions of information, education, manipulation and public debate take place.

Communication in a time of crisis can only be understood when put in the context of one of the channels through which society today is able to be in identity and in solidarity and in submission in different spheres of time – the future and the crisis. Those dimensions must be considered together as the worst mistake is to concentrate on short time spans during the time of crisis without taking into account the long, slow and meaningful process through which civic societies and public actors today are willing to find a meaningful interaction that is creative of new solidarities and consensus.

Last week, the Internet showed again its formidable rapidity: on Sunday night (May 19 2009), a prolonged but moderate earthquake shook the area of Los Angeles. Almost instantaneously, people started to flood Twitter with messages and the news of the earthquake was coursing through the world of microblogging long before the Internet press published the information. Rumours on the Internet can spread like pandemics and the way to control their nuisance could be equally employed to prevent pandemics.

Asthe main task of the World Health Organisation (WHO) is to be a worldwide health monitor, teams of the organization also dedicate themselves to track down the rumours of illnesses on the Internet in order to analyse them and evaluate the risks of pandemics. Nevertheless, the evolution of any flu virus is totally unpredictable, which makes it very difficult to foresee its extent of danger. In the case of the “swine flu”, the WHO has been very careful to prevent a repetition of the panic effect produced during the SARS epidemic. This time round, they have been more watchful with the terms used during informative campaigns. Recently, I heard on the radio a doctor working at the WHO insisting on the fact that the correct name of the flu is “A/H1N1 influenza”. Beyond what could seem to be an excess of pretentiousness, it is indeed important not to encourage false associations of ideas which could create paranoia and generate disastrous consequences such as the recent mass slaughtering of pigs in Egypt. Furthermore, the expression “swine flu” is inappropriate: despite its swine origin, the virus has not been yet isolated on animals and is only transmitted between humans. ’The Mexican flu’ or ’the North American flu” are different names used to define the A/H1N1 flu and they show how difficult it is to apprehend the pandemic, Le Monde even pinned the term “grey flu” (“grippe grise”) to underline the uncertainty experienced by organizations and States when it comes to taking decisions and measuring their efficiency.

The recent outbreak of A/H1N1 flu in Japan has caused the government to take special measures such as closing down more than 4000 schools while health officials called for calm, stressing that the virus had not caused any deaths in Japan and that most cases were relatively mild.